Health Questionnaire – 6 to 11

Health Questionnaire - 6 to 11

Personal Details

Name
Name
First
Last
Gender
Address
Address
House name / Flat No
Street address
Postcode
City
Country
Is your child the lone or partial carer for someone?
Do you consent to have messages about your child left on voicemail?
Do you consent to use of your email as a way for us to contact you about your child?
Do you consent to have messages about your child left on voicemail?

Medication

Is your child on any regular medication?
***** (Please note that you need to see a GP, if on existing medication, for a first repeat prescription to be issued. Make an appointment with a GP for a review of your medication in good time and before you run out!) *****
Is your child allergic to any medications?

Medical History

Has your child had/still have any of the following conditions:
High Blood Pressure
Diabetes
Heart Disease
Angina
Epilepsy
Stroke
Cancer
Asthma
If asthmatic, have you used your inhaler in the last 12 months?

Family History

Has a first degree relative (parent or sibling) of your child suffered from any of the following conditions?
Cancer
Stroke
Heart Disease
Diabetes
Do any other illnesses run in you family?

Contact with Other Agencies

Under the current Child Health & Wellbeing Guidance, we are obliged to ask the following for all new registrations to the Practice between the ages of 0-16 years.
Does anyone in your household currently have contact with any of the following support services?
A: Social Word Department
B: Mental Health Services
C: Drug/Alcohol Support Services

Ethnicity & Language

Do they need an interpreter or sign language support?
Choose ONE section from A to G then choose ONE option which best describes your child's ethnic group or background
A: White
B: Mixed or multiple ethnic groups
C: Asian, Asian Scottish, or Asian British
D: African
E: Caribbean or Black
F: Other ethnic group
G: Other

Confirmation

I confirm that I have read and understood this form, and completed it honestly and to the best of my knowledge
Your Name
Your Name
First
Last
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